“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”
Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.
“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”
Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended.
“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”
Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.
Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”
Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”
The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.
“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”
“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?
“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”
The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.